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Veterans Affairs Nursing in the 21st Century

The nursing shortage, the war in Iraq and increased diversity in the military are creating a whole new demand for skilled minority VA nurses

By Anne Baye Ericksen

When Lance Corporal David Coleman enlisted in the U.S. Marine Corps, he knew there was a possibility of being injured on the job-especially when he was deployed to Iraq. Unfortunately, that possibility became reality last September when his company was attacked by an improvised explosive device (IED). "The IED blast took off 80% of my calf and left me with a lot of damage on my left and right leg[s]," Coleman told National Public Radio's "Talk of the Nation."

Although fast-acting field care helped stop the bleeding and ultimately saved both limbs, Coleman faces a long road of rehabilitation. Fortunately, delivering top-notch health care for the nation's returning military veterans is what the Veterans Health Administration (VHA), a division of the Department of Veterans Affairs (VA), does best.

In the 80-plus years since Congress first established the U.S. Veterans' Bureau in 1921-the department has undergone several name changes throughout its history-the VHA has become one of the largest health care delivery systems in the nation. It is present in all 50 states, the District of Columbia, Puerto Rico, Guam and other U.S. territories, and even in the Philippines. All qualifying U.S. veterans-currently more than 25 million-have access to the system's 158 hospitals, 854 ambulatory care and community-based clinics, 132 nursing homes and more than 40 residential rehabilitation treatment programs.

Although not all veterans use its services, VHA facilities treated more than 4.8 million patients in 2003, including 742,000 inpatients. This helps explain why Congress granted the VA $29.1 billion for its fiscal year 2004 health care budget.

Because the VHA is such an extensive medical system, it's the largest employer of nurses in the world, with a total of over 60,000 RNs, advanced practice nurses, LPNs/LVNs and nursing assistants. It is also one of the nation's largest employers of minority nurses, if not the largest.

Serving Emerging Needs

A common misconception about the VHA is that all of its patients are veterans from World War II and, therefore, VA nurses spend their days caring for geriatric patients. Of course, this population segment does represent a significant percentage of the patient census, but it is by no means the only demographic. VA medical services are open to veterans from all military branches and any military operation the United States has participated in, including the Korean War, Vietnam, both Gulf Wars and Operation Enduring Freedom in Afghanistan.

"Even as the WWII vets are declining in numbers, there are new needs emerging among the younger vets from Desert Storm and Enduring Freedom," says Mary Raymer, RN, MA, CNAA, a nursing education program manager at the VA Healthcare Staff Development and Retention Office in New Orleans.

Age, however, is only one differentiating characteristic. The vets' racial, ethnic and cultural representation is equally varied. In fact, the VHA's patient base is a microcosm of the general population in terms of diversity, cultural influences and constantly evolving demographic changes. "The VHA picks up where the military leaves off," comments Rose Paradis, RN, MS, CHE, program director in the Office of Nursing Service at VA headquarters in Washington, D.C.

Traditionally, African Americans have been the VA's largest minority population, but that is slowly changing as more Hispanics, Asian Americans and American Indians retire from active duty. Additionally, women are emerging as a significant subgroup.

"Especially with the new conflict [in Iraq] underway, we are seeing more younger men and women [as patients]," states Thomas Badger, BSN, RN, MS, a nurse recruiter at the Atlanta VA Medical Center. "In fact, we're seeing an increasing number of female patients, so now we have a women's health specialty at our facility."

These trends have all affected the VHA's approach to health care delivery. "Overall, there is more of an emphasis on meeting the unique needs of the different ethnic groups than ever before," says Raymer. "That is in harmony with what's going on in health care in general. Providers are paying more attention to unique cultural and ethnic differences and how they impact treatment."

Indeed, most VHA facilities now include a cultural liaison on patients' treatment teams to address any pertinent issues that may impact the effectiveness of their care. Raymer explains, "This staff person is a patient advocate and is in the loop from the initial assessment to make sure cultural needs are met. That could include anything from patient education materials produced in a bilingual format to accommodating special religious or dietary needs."

Above-Average Workforce Diversity

Perhaps not so surprising is the fact that the VHA workforce-and its nursing staff in particular-is as diverse as its patient mix. "The VA has more ethnic diversity and male nurses than much of the private sector," notes Jacqueline E. Jackson, MSN, RN, MBA, an African-American nurse who is a recruiter at the VA Southern Nevada Healthcare System in Las Vegas.

And the numbers back this up. According to the VHA's Web site, more than half of the agency's total workforce is female and more than one third are African Americans, Hispanics, Asian Americans/Pacific Islanders or American Indians/Alaska Natives. In the nursing ranks, the statistics are similarly impressive.

"In general terms, men comprise 6% of the country's RN workforce, but in the VA system, they account for almost 15% of the nursing staff," says Raymer. "As you can see, that's more than twice [the national average]. And that's also the scenario with most ethnic groups. In the VA, African Americans make up almost 15% of the nursing ranks, compared to only 5% in the overall nursing workforce. Hispanics comprise 6% of the VA nursing staff but only 2% of the general RN population. All of these groups have increased their presence at the VA facilities during the last three years."

One reason for this success, according to Raymer and others, is the low turnover rate at many VA hospitals and community clinics.

While many private sector facilities find nurse retention a challenge, VHA nurses tend to plan their careers around the organization. "When you come to the VA, you're not just coming for a job, you're coming for a career," asserts Jackson.

"That's a reflection of the work environment and the fact that we're sensitive and open to a diverse work force," says Raymer, who has been with the VA for more than 20 years.

"Women, minorities and men all realize that once they get into the VA, there are great opportunities for a career," adds Badger, who joined the agency four years ago after completing a 24-year military career.

Emphasis on Innovation

Additionally, nurses who choose careers with the VHA find the variety of clinical specialties within the system very appealing. With the exception of obstetrics and pediatrics, the VHA offers a full range of medical services and practice settings, including medical/surgical, intensive care, psychiatric, spinal cord injury, geriatric and hemodialysis units, among others. VA nurses also work in such settings as rehabilitation centers, organ transplant centers, outpatient clinics, day treatment programs and even home-based care.

"There has been an overarching movement toward a community-based outpatient model of care [at VHA], similar to what's going on in health care in general," notes Raymer. "With [advances] in technology and providers' ability to do more things on an out-patient basis, there is decreasing need for long hospital stays."

Nurses new to the environment are often surprised-and impressed-by the advanced technology and pro-cedures found on VA nursing units. In fact, it's a myth that VA facilities lack the technical capabilities of the larger, private sector teaching hospitals.

"There were three things that drew me to the VA: the patients, the people and the technology," says Badger. "People who don't know about the VA first-hand think we're behind the times. But a number of them end up saying, 'Wow, I never believed the VA was so technologically advanced.'"

In fact, the VA has long been a health care innovator. Over the years, VA researchers have played key roles in the development of the cardiac pacemaker, the CT scan, radioimmunoassay and improvements in artificial limbs. VA clinical trials have tested the efficacy of new treatments for tuberculosis, schizophrenia and high blood pressure. Research is so important to the department that more than $400 million of its medical budget is earmarked for this purpose. Plus, the National Institutes of Health, other government agencies and pharmaceutical companies have contributed another $656 million to support the more than 10,000 research projects currently being conducted at more than 100 VA medical centers.

The benefits of these investigative inquiries certainly filter down to the bedside, where nurses can apply the advancements to their own skill sets. "Young nurses who want to be on the cutting edge of innovation want to be in this environment," says Jackson, who's been with the agency for more than 10 years.

"Our computer system is second to none. We even have information technology students from the local university come study our system. We demonstrate for them how we use high tech to provide quality care."

VA Nursing: The Next Generation

These days, the VHA is facing the same nursing shortage as its private sector peers. The current VA workforce is aging-at least one-third of its employees are over the age of 50, and only 6% are younger than age 31. With that in mind, the department is reaching out to local communities as well as the national marketplace to inform a new generation of nurses about the career opportunities today's VHA offers.

"Our facilities are well staffed, but we have to look at who's eligible to replace retiring nurses," says Paradis. "Each facility looks at its needs across the organization and various occupation categories."

Although the VHA is a national system, individual facilities recruit and hire their own staffs. "We're dealing with a real nursing shortage and we have to be competitive to attract nurses," says Jackson. "Our community [in Southern Nevada] is rapidly growing-we're planning to open a new hospital within the next five years-and we have to be extremely aggressive. Every employee is a potential recruiter."

While word of mouth seems to be one of the more successful recruiting tools, the agency is also expanding its efforts by connecting with professional nursing associations. "We have exhibits at nursing associations' national meetings,"
Raymer explains. "We also target historically black, Hispanic and tribal colleges to stimulate contact with minority students. When you encounter students who have experience in the VA, they give the most compelling testimonies. The more students involved in the system the better, because they recruit themselves.

"Our intention is to have widespread national recruitment for nurses," she continues. "But we also want to spread the message of what VA care is about."

Ultimately, that comes down to giving the nations' veterans the best possible care by employing the most diverse and qualified nursing professionals. "The patients and their families you meet on the job are what makes the difference," says Jackson.

Anne Baye Ericksen is a free-lance writer based in Southern California.

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